WOMEN OUT LOUD. Reaching the ten targets of the 2011 United Nations General Assembly

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1 WOMEN OUT LOUD how women living with HIV will help the world end AIDS Reaching the ten targets of the 2011 United Nations General Assembly Political Declaration on HIV AND AIDS

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3 WOMEN OUT LOUD how women living with HIV will help the world end AIDS Reaching the ten targets of the 2011 United Nations General Assembly Political Declaration on HIV AND AIDS

4 Copyright 2012 Joint United Nations Programme on HIV/AIDS (UNAIDS) All rights reserved The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. UNAIDS does not warrant that the information published in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. WHO Library Cataloguing-in-Publication Data Women out loud: How women living with HIV will help the world end AIDS. UNAIDS / JC2416E 1.HIV infections prevention and control. 2.HIV infections transmission. 3.Acquired immunodeficiency syndrome prevention and control. 4.Women. I.UNAIDS. ISBN (NLM classification: WC 503.6)

5 contents Reduce sexual transmission PREVENT HIV AMONG PEOPLE WHO INJECT DRUGS eliminate new hiv infections among children AND KEEP THEIR MOTHERS ALIVE 15 million accessing treatment avoid tb deaths close the resource gap eliminate gender inequalities eliminate stigma and discrimination ELIMINATE HIV-Related RESTRICTIONS ON ENTRY, STAY AND RESIDENCE STRENGTHEN hiv integration

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7 Foreword Women may make up half the world s population, but they do not share it equally. This is especially evident when it comes to HIV. Half of all people living with HIV are women, yet many are underserved or do not know their status. Despite the many successes we have seen, women still face inequalities that will keep the AIDS response from reaching its full potential. Women out loud amplifies the voices of women living with HIV so that their knowledge is shared and acted upon. This is essential to achieve the 10 targets of the 2011 United Nations Political Declaration on HIV and AIDS. Those who collaborated on this report present a snapshot of the diversity of women living with HIV. They are grandmothers, wives, mothers, transgender women, migrants and students. They include women who use drugs, women who have engaged in sex work, women who have been in prison and young women born with HIV. They are women working in grass-roots networks, international nongovernmental organizations, academia and the United Nations. They are leaders in their own right and living proof that women living with HIV can build better futures for themselves, their loved ones and their communities. This report reinforces UNAIDS efforts to strengthen the AIDS response s focus on women. We celebrate the fact that UN Women has joined UNAIDS as its 11th Cosponsor and hope that the newly created UNAIDS Women Living with HIV Dialogue Platform will bring the voices and influence of women living with HIV closer to the UN s day-to-day work. It is our collective responsibility to push for the needed changes in laws, policies, programmes and practices and to end continuing human-rights violations and gender inequalities that enable HIV to spread. The full involvement of men, and securing their commitment to change, must be central to these efforts. As this report testifies, women s leadership, resilience and good practices to transform societies are widespread. What is needed now is stronger support for women s full participation in the response to HIV, and better data to track progress as it relates to women. This requires a concerted effort to promote and protect the rights of women and of all people living with HIV. When women speak out, we must listen carefully, and act with solidarity and commitment to transform words into action. Michelle Bachelet, Executive Director, UN Women Jennifer Gatsi-Mallet, Executive Director, Namibian Women s Health Network Michel Sidibé, Executive Director, UNAIDS

8 reduce sexual transmission!

9 1 MINUTE Each minute, one young woman is infected by HIV. 49 % Women represent 49% of all adults living with HIV Female sex workers are 13.5 times more likely to be living with HIV than other women.

10 Target 1 reduce SEXUAL TRANSMISSION OF HIV by 50% by WOMEN REPRESENT 49% OF ALL ADUlts LIVING WITH HIV. IN most AFFected REGIONS, SUCH AS AFRICA AND THE CARIBBEAN, ABOUT 60% OF PEOPLE LIVING WITH HIV ARE WOMEN. Introduction Globally, young women aged are most vulnerable to HIV, with infection rates twice as high as in young men, at 0.6%. This disparity is most pronounced in sub-saharan Africa, where 3.1% of young women are living with HIV, versus 1.3% of young men. Each minute one young woman acquires HIV, accounting for 22% of all new HIV infections (1), with sexual transmission being the dominant mode of infection (2). Much remains to be done to ensure that young people are able to correctly identify ways of preventing the sexual transmission of HIV (Fig. 1.1). Even in cases where HIV knowledge exists, harmful gender norms can act as barriers for women to negotiate condom use and otherwise protect themselves from HIV (3, 4, 5, 6). Surveys show that in 12 of 19 countries with available data, less than 75% of women believe that a woman is justified in refusing to have sex with her husband when she knows he has sex with other women (Fig. 1.2). As a 2005 WHO multicountry study (7) showed, there is a close link with violence. The proportion of women physically forced into intercourse ranged from 4% to 46%, while 6% to 59% of the women reported sexual abuse by a partner. This high rate of forced sex is particularly alarming in the light of the AIDS epidemic and the difficulty that many women have in protecting themselves from HIV infection. 10 UNAIDS Women out loud

11 figure 1.1. Percentage of young women and men aged who correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission, generalized epidemics Sierra Leone (2008) Zimbabwe* ( ) Zambia (2009) Uganda* (2010) Togo (2010) Tanzania (2010) Swaziland (2007) Rwanda (2010) Nigeria (2008) Namibia (2006) Mozambique (2009) Malawi (2010) Liberia (2007) Lesotho (2009) Kenya ( ) Haiti (2005) Guinea-Bissau (2010) Guinea (2005) Ghana (2008) Ethiopia (2011) Eritrea (2002) Djibouti (2006) Democratic Republic of the Congo (2007) Côte d Ivoire* (2005) Burkina Faso* (2010) Benin (2006) Angola ( ) 0.00% 20.00% 40.00% 60.00% 80.00% % Source: Demographic and Health Surveys and other population-based behavioural survey data. Percentage (Females 15-24) Percentage (Males 15-24) UNAIDS Women out loud 11

12 figure 1.2. Percentage of women reporting that they agree with the statement that a wife is justified in refusing sex with her husband if she knows he has other partners Rwanda 2005 Ethiopia 2011 Lesotho 2004 Ghana 2003 Kenya 2003 Namibia 2000 Uganda 2001 Tanzania 2005 Zambia 2002 Chad 2004 Malawi 2004 Nigeria 2003 Burkina Faso 2003 Senegal 2005 Cameroon 2004 Benin 2006 Mozambique 2003 Guinea 2005 Mali Source: Demographic and Health Surveys, Interestingly, women s attitudes towards refusing sex barely change across the different age groups, pointing to persistent socially and culturally defined ideas about gender attitudes and behaviour. Lack of economic empowerment also makes women more vulnerable to sexual transmission of HIV. Studies in low- and middle-income countries show that financially autonomous women find it easier to negotiate condom use with their husbands. Factors such as experience with an at-risk partner, the desire to maintain good social standing, fear of acquiring HIV and parental guidance and support influence women to reduce perceived HIV risk, despite constraining 12 UNAIDS Women out loud

13 gender norms and power imbalances in a marriage. Findings suggest that improving women s social and economic status can cut their risk of acquiring HIV by reducing dependence on male partners and enhancing their decisionmaking power (8). Studies on cash transfers among secondary school-aged young women in Malawi showed that such transfers not only encouraged women to reduce their risky sexual behaviour in the short term, but also resulted in a reduction in teenage pregnancy, as well as lower self-reported sexual activity (9, 10). Female sex workers can also be particularly vulnerable to HIV (see Table 1.1), with country-reported prevalence among this key population in capital cities of more than 20% for some countries. Meanwhile, a recent review of data from 50 countries found that female sex workers were 13.5 times more likely to be living with HIV than were other women (11). Worldwide, the available evidence suggests that HIV prevalence rates reach as high as 68% in transgender communities (12). WHO defines transgender as an umbrella term for persons whose gender identity and expression does not conform to the norms and expectations traditionally associated with the sex assigned to them at birth. Incidence among transgender persons ranges from 3.4 to 7.8 per 100 person-years in some countries (12). In the United States of America, rates for newly identified infections among transgender women are threefold higher than for transgender men (13). Empowering women There has been growing recognition of how sociocultural factors driving gender inequalities critically influence the risk of HIV infection. This is particularly true of the role of gender norms and how they impact on HIV acquisition in women and affect women s access to services and social support. Women s particular vulnerability to HIV makes a better understanding of gender barriers to HIV transmission paramount. WE WOMEN LIVING WITH HIV ARE KEY TO CREATING SAFE ENVIRONMENTS AND EFFECTIVE STRATEGIES TO REDUCE HIV. UNAIDS Women out loud 13

14 TABLE 1.1. Country-reported prevalence among female sex workers in capital cities >20% 10 20% 5 10% <5% Chad Ghana El Salvador Afghanistan Romania Latvia Togo Cape Verde Bosnia and Herzegovina Montenegro* Nigeria Cambodia Eritrea Japan Armenia Kenya Djibouti Estonia Mongolia Kazakhstan United Republic of Tanzania Burkina Faso Algeria Somalia Timor-Leste Mauritius Guyana Lithuania South Sudan Nepal Guinea Senegal Indonesia Czech Republic Argentina Côte d Ivoire Papua New Guinea Angola Germany Thailand Uganda Burundi Mauritania Sri Lanka Panama Niger Portugal Belgium Georgia Guinea-Bissau Haiti Philippines Nicaragua Zimbabwe Ukraine Madagascar Morocco Rwanda Myanmar Bangladesh Paraguay Swaziland Bulgaria Netherlands China Uzbekistan Cuba Honduras Spain Colombia Bolivia Viet Nam Pakistan Kyrgyzstan Tunisia Iran Mexico Guatemala Serbia* Suriname Azerbaijan Tajikistan Belarus Jamaica Lao People s Democratic Republic Source: 2012 Country progress reports (www.unaids.org/cpr) Reducing sexual transmission by 50% by 2015 requires scaled-up access to comprehensive and nonjudgemental HIV services for women and girls throughout their lives. It will also be necessary to scale up access to comprehensive sexuality education in and out of school, and to expand youthfriendly services that empower young women to protect themselves (14, 15, 16). Recent evidence shows the cost effectiveness of delivering sexuality education programmes and services jointly at scale has the strongest impact (17). Investing in research into female-controlled prevention technologies is also essential. These include microbicides, pre- and post-exposure prophylaxis and female condoms, as well as working with networks of women living with HIV and women s organizations to ensure access to these technologies for women and girls. 14 UNAIDS Women out loud

15 WOMEN OUT loud Jane Bruning, Elisha (Rina) Kor, Annah Sithembinkosi Sango Women and girls account for more than half of people living with HIV globally, and must be equal and valued partners in decision-making if sexual transmission of HIV is to be reduced by 50% by But, almost 30 years since the onset of the HIV epidemic, there has been a failure to meaningfully engage women living with HIV as leaders in prevention efforts. A critical enabler to reaching the target of reducing sexual transmission of HIV by 50% by 2015 is ensuring that we women living with HIV are empowered, and that laws protect our right to choose with whom and how we have sex, and who we choose to marry, and when and whether or not we will have children. However, despite decades of advocacy and evidence, the voices of women and girls remain on the margins, and many young women still cannot or do not know how to protect themselves. Our vulnerability to HIV in many cultures is due to our position in society, and those of us who are young are at an increased risk of contracting HIV. Cultural expectations of masculinity encourage men to assume the patriarchal attitude that wives, partners and daughters are the possessions of men, and most husbands expect or demand their conjugal rights. There is a strong link between gender-based violence and HIV. Violence, or the fear of violence, sometimes prevents women, transgender women and girls from negotiating safer sex, discussing fidelity with their partners or leaving risky relationships. No man should have the right to beat his wife, force her to have sex or throw her out of her home with nothing, simply because she is the first to be diagnosed with HIV, but this is happening. Poverty is another driver of HIV transmission. Many women and girls turn to transactional sex as a means of sustaining their livelihoods and young girls are often coerced into sexual activities with older men. Women who engage in sex work are vulnerable to violence, and consequently HIV, through police persecution and lack of agency when clients demand sex without condoms. Carrying condoms can risk a police search that may result in a prosecution for sex work. Transgender women (i.e. male-to-female transgender persons), who are often homeless and jobless, frequently suffer the double stigma of living with HIV and being transgender women. Many countries do not recognize transgender women, which leaves them with little or no choice but to turn to sex work as their only source of income. Similarly, women who use drugs are generally unable to access harmreduction services and may engage in sex work to sustain their drug habits. All of this places women who use drugs at further risk of contracting HIV and possibly coinfection with hepatitis through sexual transmission. UNAIDS Women out loud 15

16 Today, migrant women and girls experience harsh working conditions and are more at risk of contracting HIV by being separated from their families and communities. Migrants are often unable to access health-care services as these are not specifically designed to reach people on the move. Thirty years into this epidemic, we are still arguing over what information young people are ready for. Young people have sex for exactly the same reasons as adults: procreation, pleasure, income or to avoid being beaten. How will young women know to avoid harm if we are not talking to them about sex and how to negotiate safer sex? We know what we need In some countries, treatment as prevention is being seen as a silver bullet to address the epidemic. This is premature as systems are not able to sustain this approach and there are long-term side-effects and complications from taking antiretroviral medications. This is particularly pertinent for pregnant women who, in some countries, are being encouraged to use treatment to prevent the vertical transmission of HIV to their child and to subsequently stay on treatment irrespective of their CD4 count. This is known as Option B+. While treatment enables us to pose less of a risk to our unborn infants and also to our HIV-negative partners, we should be the ones making decisions about when and if we begin treatment. The choice to begin treatment is an individual one, which every woman should be empowered to make. If a woman chooses to begin treatment she should have access to consistent and reliable life-saving antiretroviral medications for her own well-being and not just because it is good for public health. Many of us have spoken out in the hope that others will learn from our experiences, and have helped develop the skills of others to do the SAME. 16 UNAIDS Women out loud

17 A successful rights-based response to HIV prevention requires the involvement of women living with HIV, especially young women, at all levels in the design and implementation of policies and programmes. Even though our perspectives are not often considered important in the HIV response, there are many strong and brave women living with HIV who have started communitybased organizations, as well as regional and global networks. We are raising awareness of HIV through our leadership role in positive health, dignity and prevention. This new approach to programming encompasses improving and maintaining the dignity of individuals living with HIV and supporting and enhancing their physical, mental, emotional and sexual health, resulting in an enabling environment that will reduce the likelihood of new HIV infections. Women living with HIV have developed training tools on gender, communication and relationships for older and younger women and men to address their vulnerabilities and reduce gender violence. Due to patriarchy and many older people s repressive attitudes towards young women, these programmes are critical. One such example is Stepping Stones, currently implemented in 100 countries. Many of us have spoken out in the hope that others will learn from our experiences, and have helped develop the skills of others to do the same. Lifting the burden of secrecy, one such training package, has been translated into eight languages. Projects such as these are grassroots initiatives that have been successfully embraced on a global scale. They all address elements of HIV education and prevention. We, women living with HIV, know which programmes have failed us and why. We are key to creating safe environments and effective strategies to reduce HIV and provide high-quality services to all women, irrespective of where we live, our age, profession or lifestyle. Jane Bruning is the National Coordinator, Positive Women Inc., New Zealand; Elisha (Rina) Kor is Programme Manager at the PT Foundation, Malaysia; and Annah Sithembinkosi Sango is a member of the International Community of Women Living with HIV/AIDS Southern Africa, Zimbabwe. Action points Uphold our rights and eliminate laws and policies that do not advance gender equality. Resource our networks as key partners in reducing new transmissions. Organize strategic engagement between us and government, civil society and religious agencies on HIV prevention. Ensure access to comprehensive sexuality education and contraceptive options for all women, especially young women. Uphold sex workers rights to ensure safety at work. UNAIDS Women out loud 17

18 PREVENT HIV AMONG PEOPLE WHO INJECT DRUGS

19 50 % Women who inject drugs have a 50% higher prevalence of HIV than their male peers. 8 % Globally, 8% of people who inject drugs have access to needle and syringe programmes.

20 Target 2 REDUCE transmission OF HIV AMONG PEOPLE WHO inject DRUGS BY 50% by WOMEN LIVING WITH HIV WHO USE OR HAVE USED DRUGS may ALSO BE EXPOSED TO BReaches OF confidentiality, WHICH may THEN HEIGHTEN THE RISK OF VIOLENCE AND ABUSE (1). Introduction Despite the fact that more countries than ever are reporting data on people who inject drugs, they remain the lowest reported key population. Moreover, data on females who inject drugs in concentrated epidemics is less reported than data on males for all indicators in the 2012 Global AIDS Response Progress Reporting submissions (see Figure 2.1). Studies conducted in nine European Union countries have indicated on average a 50% higher prevalence of HIV among women who inject drugs than their male peers (2). In the Philippines, estimates suggest that almost 14% of people who inject drugs are living with HIV, yet prevalence among women who inject drugs is 27%, more than twice that of their male counterparts at 13% (3). Country-reported data on levels of access to safe injecting equipment appears to be similar for both sexes, at close to 80%. However, this reporting most likely represents an overestimation of the coverage of needle and syringe programmes. A global review found that only 8% of people who inject drugs had access to needle and syringe programmes (estimate based on service coverage data from 102 countries). There are also substantial variations in regional and national coverage (4). 20 UNAIDS Women out loud

21 figure 2.1. number of COUNTRIES with concentrated epidemics reporting on indicators pertaining to people who inject drugs, by sex. 20 Number of countries reporting 0 Male Female People who inject drugs: Condom use People who inject drugs: Safe infecting People who inject drugs: Testing People who inject drugs: HIV prevalence Source: 2012 country progress reports (www.unaids.org/cpr). Even where harm-reduction programmes are in place, women who use drugs may face a range of gender-specific barriers to accessing HIV-related services (5). Recent studies indicate that women who inject drugs are more exposed to violence from intimate partners, police and sex-work clients (6). Added to this, homelessness and psychiatric illness can further increase exposure to HIV infection (7, 8). Women who use drugs are widely reported to experience disproportionate levels of stigma and discrimination, often compounded during pregnancy, and as mothers (9, 10, 11). Studies have also shown infrequent use of condoms by women who use drugs with long-term and casual partners, and a correlation between inconsistent condom use and the sharing of injection equipment (12). Women who use drugs may be unable to negotiate condom use due to unequal relations with their partners. When sex is exchanged for drugs or other resources, women often exert little influence over a partner s condom use (10). UNAIDS Women out loud 21

22 Pushing for policy change The commitment to reduce by 50% transmission of HIV among people who inject drugs by 2015 is an historic one, which recognizes the specific vulnerability of this population. Stronger monitoring systems for people who inject drugs are needed to fulfil this commitment, as is gender-disaggregated data related to service uptake and accessibility. Scaling up evidence-based harm-reduction services, including those for opioid substitution therapy and needle and syringe programmes, will be critical. Women living with HIV who inject drugs must be meaningfully engaged in conceptualizing and delivering such services to ensure they are women-friendly and address their often multiple and complex needs. Specific efforts must be made to integrate HIV, sexual and reproductive health and harm-reduction services, through, for example: training service staff to provide opportunities for couples counselling, empowering women to negotiate safer injecting and sexual practices within their relationships; providing services and support specific to women; and opening centres with child-care facilities for those women who are primary caretakers (5). Women who inject drugs must have access to confidential and voluntary HIV counselling and testing. They also need reliable information and access to sexual and reproductive services for ending new infections in children and keeping mothers alive, as well as to protect their own health, free of stigma and discrimination. Laws and policies that punish, stigmatize and discriminate against women living with HIV, as well as women who use drugs, create a significant barrier to women accessing both harm-reduction and HIV-related services. Greater strides must be taken to ensure all policies and initiatives are evidenceinformed and uphold the rights and dignity of all women. The fact that we use drugs does not MEAN we are useless or powerless and, given the chance, we can achieve great things. 22 UNAIDS Women out loud

23 Women out loud Frika Iskandar, Filia Jung, Silvia Petretti The target to reduce transmission of HIV among people who inject drugs by 50% by 2015 is critical, but it cannot be accomplished unless stigma, discrimination, criminalization and violence are addressed and we women living with HIV, who are or have been drug users, are engaged in developing and leading interventions. Most literature on people who inject drugs does not differentiate between men and women, yet we have our own specific risks and needs. As women who inject drugs, we have significantly higher mortality rates, are more likely to face injection-related problems, have faster progression from first use to dependence, and engage in more risky injection and sexual-risk behaviours compared with men who use drugs (10). We are disproportionately more likely to have HIV, and we have higher rates of other sexually transmitted infections, hepatitis B and C, and tuberculosis (10). Our vulnerability is compounded by gender, power and other structural dynamics and imbalances. To reduce transmission of HIV among people who inject drugs by 50% by 2015 in an equitable way for women, it is paramount to first gain a better understanding of our lives. We face profound stigma, discrimination and violence, including from HIV, drug and other service providers. Because our rights are often violated, remaining invisible is often our best survival mechanism. Drug use and sex work are criminalized in most countries, and sexual transmission of HIV is criminalized in an increasing number. Revealing our HIV status may not only mean that we will be ostracized, but can also put us in prison. When we are in prison, we have little to no access to opioid substitution, antiretroviral therapy and other medical treatment. Reaching us can be a great challenge. Many of us want to stop injecting drugs but we have little access to appropriate opioid substitution and womenfocused rehabilitation and detoxification services. It is difficult for women who use drugs to access appropriate, safe, skilled and respectful sexual reproductive health and maternal, natal and child-health services. Often even within HIV support organizations, those of us who are pregnant are treated in a negative way, as if we cannot possibly be good mothers. But those of us who use drugs have the same desires and rights as all other women. In many countries, families will help men who use drugs, whereas women who inject are thrown out on the streets for disgracing their family. Until recently, there were no drug treatment facilities for women in the Middle East and in most of Africa. UNAIDS Women out loud 23

24 Health system failures To deal with our own health and life can be complex and overwhelming. Not only do we use drugs and have to deal with HIV, we may also have hepatitis B and C, tuberculosis or multi-drug-resistant tuberculosis. It is essential that services for women living with HIV are not judgemental and are specialized to deal with the complexities around gender-based power and violence, drug use, HIV and hepatitis and tuberculosis coinfection. We have the right to and need for treatment, but often health workers will not give us medicine: they assume we will be non-compliant. We experience discrimination and stigma when we try to get services, including antiretroviral therapy. Our needs can easily fall through the cracks. While there is some evidence that lesbian and bisexual women are more likely to use drugs and alcohol compared with heterosexual women, there are few services for those of us who have sex with women, and the needs of us who are transgender, HIV positive and inject drugs are almost always ignored (13). Those of us who inject drugs and do sex work have different risks and vulnerabilities to other women who use drugs but do not engage in sex work, or who perform sex work and do not inject drugs. We can lead All that said, the fact that we use drugs does not mean we are useless or powerless. With the right structure, acceptance, recognition and support, drug users can achieve great things, and we know many examples of successful involvement and leadership among women living with HIV who use drugs. Many of us, when given the chance, have skilled up, and helped other women and men. We have set up new organizations and made a difference, taking the lead and making sure women s issues are voiced and addressed. Some of us have become professionals in this arena. Because our rights are often violated, remaining invisible is often our best survival mechanism. 24 UNAIDS Women out loud

25 For example, the HIV network in Indonesia (Ikatan Perempuan Positif Indonesia) is led by a group of women living with HIV with an injecting druguse background. Another example of good practice and the agency of women with HIV who use or have used drugs is the All-Ukrainian Network of People living with HIV. This organization has produced excellent documentation on how women living with HIV on opioid substitution can go on being good mothers, living satisfying lives. However, there has been little other documentation of our successes. The importance and success of our leadership as women living with HIV who use drugs is rarely acknowledged. We need to further build our skills and capacities so we can take control of our lives and contribute to our communities. We need more appropriate space and resources to demonstrate how to better work with us and to provide evidence of our impact. Frika Iskandar is a member of the women s working group, Asia Pacific Network of PLHIV, Indonesia; Filia Jung is a member of the International Community of Women Living with HIV/AIDS, United States of America; Silvia Petretti is Deputy CEO of Positively UK and Coordinator of PozFem UK, United Kingdom. Action points Trust us to take care of ourselves and be an integral part of policy-making and programming, including those of us who are still active drug users. Fund us and invest in interventions and policies specifically for women who inject drugs, including peer-developed and peer-implemented programmes, where we can be trained, supported and paid for our work. Treat us holistically with more respect via integrated services for HIV, hepatitis, tuberculosis, sexual and reproductive health and drug use, including opioid substitution therapy, overdose prevention and access to clean injecting equipment. Make us and our lives visible, with gender-specific monitoring indicators for interventions with people who inject drugs in order to show gaps and build evidence for increased attention to our needs and priorities. Support us, especially when we are most marginalized. We need access to services for lesbian, bisexual and transgender women who use drugs, who do sex work and/or are in prison. UNAIDS Women out loud 25

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